Pain and spinal cord compression are two of the most distressing problems in patients with advanced cancer. Guidelines for management of spinal cord compression in these patients exist and can be used effectively by family physicians. Mild pain (step 1) should be treated with nonopioid agents, and moderate or severe pain (step 2 or step 3) is treated with other agents, including opioids. In a paper developed for the American College of Physicians–American Society of Internal Medicine End-of-Life Care Consensus Panel, Abrahm describes the course of pain management in a typical patient with advanced cancer who has refractory metastatic spread to the vertebrae.

Pain intensity should be assessed using a numeric or verbal pain scale to identify appropriate pharmacologic agents for initial therapy (see accompanying table). Therapy for bone pain that is too diffuse for palliative radiation is pharmacologic; adjuvant therapy with acetaminophen is often helpful. Nonsteroidal anti-inflammatory drugs also can be used if there are no contraindications. Misoprostol or omeprazole can be used in patients with a history of ulcers and in those at a higher risk for gastrointestinal disturbances. After therapy is initiated, a repeat assessment of pain intensity enables medication adjustments.

Believe the Patient's Report of Pain

To assess and manage the patient's pain, use a pain scale.

For mild pain (pain score: 1 to 4 on a zero-to-10 scale), start with aspirin, acetaminophen or an NSAID.

If the pain is not relieved or is moderate (pain score: 5 to 6), add oxycodone, tramadol or hydrocodone (or use a combination product that contains 5 mg of oxycodone or hydrocodone with aspirin, acetaminophen or NSAID).

For severe pain (pain score: 7 to 10), start therapy with oxycodone alone, hydromorphone or morphine. If transdermal opioid is desired, consider using transdermal fentanyl after the effective opioid dose has been identified by using immediate-release agents.

Transdermal fentanyl has a 14- to 24-hour “on” and “off” time.

If the pain is excruciating (pain score: 10 or higher), increase the opioid dose by 50 to 100 percent regardless of the amount of drug given, until pain is relieved.

For chronic pain, give around-the-clock therapy or “patient may refuse,” not “as-needed” therapy.

For pain between doses, give 10 percent of the total daily opioid dosage in immediate-release form (for example, the rescue dose for 200 mg of opioid is 20 mg).

Always prescribe a laxative (such as senna, with or without lactulose); do not give “as needed.” Patient may need an antiemetic for two to seven days.

Believe the Patient's Report of Pain

To assess and manage the patient's pain, use a pain scale.

For mild pain (pain score: 1 to 4 on a zero-to-10 scale), start with aspirin, acetaminophen or an NSAID.

If the pain is not relieved or is moderate (pain score: 5 to 6), add oxycodone, tramadol or hydrocodone (or use a combination product that contains 5 mg of oxycodone or hydrocodone with aspirin, acetaminophen or NSAID).

For severe pain (pain score: 7 to 10), start therapy with oxycodone alone, hydromorphone or morphine. If transdermal opioid is desired, consider using transdermal fentanyl after the effective opioid dose has been identified by using immediate-release agents.

Transdermal fentanyl has a 14- to 24-hour “on” and “off” time.

If the pain is excruciating (pain score: 10 or higher), increase the opioid dose by 50 to 100 percent regardless of the amount of drug given, until pain is relieved.

For chronic pain, give around-the-clock therapy or “patient may refuse,” not “as-needed” therapy.

For pain between doses, give 10 percent of the total daily opioid dosage in immediate-release form (for example, the rescue dose for 200 mg of opioid is 20 mg).

Always prescribe a laxative (such as senna, with or without lactulose); do not give “as needed.” Patient may need an antiemetic for two to seven days.

Opioids should be prescribed at dosages high enough to relieve the pain and frequent enough to prevent recurrence. A rescue dose of a short-acting opioid should be provided for unanticipated exacerbations of pain. These medications include morphine, oxycodone or hydromorphone, starting at 10 percent of the total daily opioid dose and given every one to two hours as needed. Sustained pain relief can be achieved with long-acting preparations, such as sustained-release oxycodone, morphine preparations or transdermal fentanyl. Meperidine is not indicated for treatment of chronic pain because of its short half-life and associated toxicity profile. Patients often need help accepting opioid treatment because of unwarranted concerns about addiction or feeling “high.” The most effective daily treatments for opioidinduced constipation are senna, senna combined with a stool softener, Phillips' Milk of Magnesia (magnesium hydroxide) or lactulose. Increasing fiber consumption may exacerbate the problem in more debilitated patients.

Physical and cognitive therapies can decrease the experience of pain. Positioning, exercise and assist devices, along with cold, heat and massage, can be helpful as well. Cognitive therapies include progressive muscle relaxation and hypnosis. Other therapies include biphosphonates in patients with multiple myeloma and breast cancer, radiation therapy and other radiopharmaceutical agents.

The author concludes that therapy for patients with advanced cancer requires a team approach, with the family physician providing a leadership role.